CONCEPT OF HEALTH AND DISEASE(1, 2)

Health
The world Health Organization (WHO) described health in1948, in the preamble to its constitution,
as “A state of complete physical, mental, and social well-being and not merely the absence of disease
or infirmity”. Some other dimensions like spiritual, emotional may also be included.
Health Promotion
Health promotion is the process of enabling people to increase control over, and to improve, their
health. It moves beyond a focus on individual behaviour towards a wide range of social and
environmental interventions (WHO)
Health promotion are strategies aimed at improving the level of health of individuals, families, and
ommunities.
Health promotion involves the empowerment of the community in improving its health through
1. health education
2. provision of preventive health services
3. improvement of the social, physical and economic environments
It depends on:
1. Knowledge: learning new information about the benefits or risks of health related behaviors.
2. Techniques: applying new knowledge to everyday activities; developing ways to modify
present lifestyles.
3. Community supports: availability of environmental or regulatory measures to support new
health promoting behaviors within a social context.
Disease:
Disease is any deviation from or interruption of the normal structure or function of any part, organ,
or system of the body that is manifested by a characteristic set of one or more signs, or symptoms. (U
S Food and Drug Administration (FDA) 1998)

Determinants of Health or Ill Health: “BEINGS Model”

Determinants of health are a range of factors that influence the health status of individuals or
populations. At every stage of life, health is determined by complex interactions between social and
economic factors, the physical environment and individual behaviour. ... Income and social status.
Social support networks.
1. Biologic factors and Behavioral factors:
2. Environmental factors
3. Immunologic factors
4. Nutritional factors
5. Genetic factors
6. Services, Social factors, and Spiritual factor

Natural History of Disease(1, 2)

The natural history of disease refers to a description of the uninterrupted progression of a disease in
an individual from the moment of exposure to causal agents until recovery or death.
The natural history implies the course and outcome, of disease (the way it progresses), both in
individuals and in groups. In the absence of medical or public health, intervention is called the
“natural history of disease” (Figure 1).
Public health and medical personnel take advantage of available knowledge about the stages,
mechanisms and causes of disease to determine how and when to intervene. Knowledge of the
natural history of disease ranks alongside causal understanding in importance for disease prevention
and control. The goal of intervention, whether preventive or therapeutic, is to alter the natural history
of disease in a favorable way. Natural history of disease involves 4 stages

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 1. Stage of susceptibility (Predisease stage, Stage of good health)
It is a stage of good health before the pathologic process begins.
The process of disease begins with the appropriate exposure to or accumulation of factors sufficient
for the disease process to begin in a susceptible host. For an infectious disease, the exposure is a
microorganism. For cancer, the exposure may be a factor that initiates the process, such as
components in tobacco smoke (for lung cancer), or one that promotes the process, such as estrogen
(for endometrial cancer).
2. Stage of subclinical disease (Latent stage, asymptomatic stage,)
After the disease process has been triggered, pathological changes then occur without the individual
being aware of them (Subclinical changes).
During this stage, disease is said to be asymptomatic (no symptoms) or inapparent
This stage of subclinical disease, extending from the time of exposure to onset of disease symptoms,
is usually called the incubation period for infectious diseases, and the latency period for chronic
diseases.
3. Stage of clinical disease (Symptomatic stage)
The onset of symptoms marks the transition from subclinical to clinical disease. Most diagnoses are
made during the stage of clinical disease. The onset of symptoms marks the transition from
subclinical to clinical disease. Most diagnoses are made during the stage of clinical disease. In some
people, however, the disease process may never progress to clinically apparent illness. In others, the
disease process may result in illness that ranges from mild to severe or fatal. This range is called the
spectrum of disease. Ultimately, the disease process ends in either recovery, disability or death.
4. Stage of Recovery, Disability or Death
In some people, the disease process may never progress to clinically apparent illness. (recovery)
In others, the disease process may result in a wide spectrum of clinical illness (disability), ranging
from mild to severe or fatal (death)
Figure 1 demonstrates the different stages in the natural history of the disease

Figure 1.Natural history of the disease

PREVENTIVE MEDICINE

Prevention is better than cure is one of the prime messages of public health. It differentiates public
health from the clinical disciplines that are primarily involved with the care of the sick, whilst public
health emphasizes the avoidance of illness.
Ideally, prevention occurs before people contract a disease, so preventive programs are oftendelivered
to currently healthy people in the general population. But at what stage in the naturalhistory should we
intervene? The metaphor of the “iceberg of disease” reminds us that for everycase that comes to a
clinician, there are likely to be many more people with pre-clinical disease inthe community, and even
more with risk factors for the condition. For some conditions (water-borneparasitic diseases,
respiratory disease due to air pollution) virtually everyone in the population issusceptible, so
prevention can justifiably target the entire population. For other conditions (e.g.breast cancer) some
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groups are at higher risk, so prevention can focus on those distinguished population(3).
Prevention was initially construed narrowly in terms of protective measures like vaccination and
improved nutrition that target only healthy people with the aim of preventing the onset of disease.
This concept was extended to cover the early diagnosis and treatment of sick persons with the aim of
preventing advanced diseases and in the case of communicable diseases, in preventing the spread
within the community. A further extension of the definition covers the treatment of sick individuals
aimed at reversing damage and restoring function. This concept led to the classification of prevention
into three levels later to be differentiated into five stages:

Levels of prevention:
1- Primordial prevention
Primordial prevention consists of actions to modify population health determinants and inhibit the
establishment of factors (environmental, economic, social, behavioural) known to increase the
future risk of disease. It addresses determinants at the systemic level rather than modifying
personal risk factors, which is the goal of primary prevention.
e.g. outlawing alcohol, improving sanitation, establishing healthy communities, promoting a
healthy lifestyle in childhood (for example, through prenatal nutrition programs and
supporting early childhood development programmes), or developing green energy
approaches
2- Primary prevention
Early intervention during predisease stage may prevent exposure to the agent of disease
preventing the disease process from starting, therefore it is called primary prevention
It includes two stages:
A. General health promotion
For healthy individuals with no known risk factors: primary prevention should be health
promotion (e.g., encouragement of healthy changes in lifestyle, nutrition, and
environment).
Target population: entire population with special attention to healthy individuals
Objective: prevent onset of illness
Methods: education, nutrition, sanitation, life style changes, etc.
B. Specific prophylaxis
For healthy individuals with disease susceptibility: primary prevention should include
specific protection (e.g., recommendations for nutritional supplements, immunizations,
and occupational and vehicle safety measures).
Target population: entire population with special attention to healthy individuals with
disease susceptibility
Objective: prevent onset of specific diseases
Methods: education, immunization, nutritional supplements (vitamin A, iodine),
chemoprophylaxis (e.g. against malaria).
3- Secondary prevention
During the latent stage of the disease when the disease process has begun, but is still
asymptomatic screening and giving appropriate treatment may prevent progression to
symptomatic disease this is called secondary prevention. Secondary prevention should focus
on screening for populations or case findings for the individual in medical care and, if disease
is found, treatment. It is the stage of early diagnosis and treatment
Target population: sick individuals
Objective: early diagnosis and treatment to prevent further damage to the individual and
in cases of infectious diseases, spread to the community
Methods: screening of high risk groups e.g. ECG, Pap smears, sputum examination for
TB, blood test for HIV, monitoring of vulnerable groups (children, pregnant women).
4- Tertiary prevention
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 During the symptomatic stage when disease manifestations are evident intervention may slow,
arrest, or reverse the progression of the disease, this is called tertiary prevention. It includes
two stages:
A. Initial care (disability limitation):
Tertiary prevention should focus on disability limitation (i.e., medical or surgical
treatment to limit damage from the disease with primary prevention measures).
Target population: sick patients
Objective: limit (reduce) damage from disease
Methods: skilled clinical care and social support to limit physical and social damage
from the disease
B. Subsequent care (Rehabilitation)
Tertiary prevention should focus on rehabilitation (i.e., teaching of methods to reduce
social disability).
Target population: convalescent patients
Objective: restore function and capability
Methods: physical and social rehabilitation
Table 1 illustrates the modes of interventions at the different levels of prevention.

Table 1 Modes of interventions at the different levels of prevention

LEVELS OF Primordial Secondary
PREVENTI0N
Primary prevention Tertiary prevention
prevention prevention
Modification of Early
MODES OF Health Specific Disability
INTERVENTION
population health diagnosis and Rehabilitation
promotion prophylaxis limitation
determinants treatment

Figure 1 demonstrates the Leavell’s levels of prevention in relation to the natural history of the
disease

Onset of Usual time of

symptoms diagnosis
Exposure
Pathologic
changes

Stage of Stage of Stage of Stage of

susceptibility subclinical clinical recovery,
disease disease disability or
death

PRIMARY
PREVENTION SECONDARY TERTIARY
PREVENTION
PREVENTION

Figure 1. Leavell’s levels of prevention

References
1. CDC. Principles of Epidemiology, 2nd Edition-Selected Lessons. 2nd ed2012.
2. CDC. Principles of Epidemiology _ Lesson 1 - Section 9 Natural history of disease. 2012.
3. AFMC. AFMC Primer on Population HealthA virtual textbook on Public Health concepts for Clinicians,. 2022.

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